For as long as I can remember advocates of patient safety have both held the–very safe–aviation industry up as a useful analogue to health care.

But this blog entry in the WSJ calls the analogy into question. At least it calls into question the simple (simplistic) imitation of the practices of aviation that are commonly seen as solutions to many patient safety problems in health care.

The Obama administration next week will embark on a fresh pitch for the health-care overhaul, seeking to boost public support for the law on its one-year anniversary.

But lawmakers and some policy experts say the next phase of the overhaul will be more difficult to sell. Between now and the 2012 presidential election, few consumer-oriented changes kick in. That gives the administration few tools to break a deadlock in public opinion over President Barack Obama’s top domestic achievement, which he signed March 23, 2010.

Some polls show that 66% of people have no idea how the law will affect them. Looks like the White House has its work cut out for it.

First, it needs to be said that NO ONE knows what ACOs are or will look like. There has been a pilot, which was quite successful. But CMS was set to clarify regs for ACOs and has missed the deadline. And there’s little indication when the guidelines will emerge.

Second, I’ve heard policy analysts report that the one most important thing for success in ACOs is “culture.” I really didn’t see that coming; yet it makes perfect sense.

Finally, ACOs–to date–are focused on docs and their behavior. The article I link to above argues that patients ought to be included in ACOs. Healthy behaviors can, the authors rightly mention, be part of the ACO calculation.

Nevertheless, I’m not sure how CMS can share gains in this way. It’s an interesting idea. And, in my view, shows promise.

The Dartmouth Atlas issued a report on end-of-life care in some cancer patients.

The long and short of the paper is–from my limited perspective–that hospice is underutilized. My experience is that among clinicians, there are common misconceptions about what hospice organizations do. (Most people think hospice cuts off other treatment programs and/or as merely palliative care–pain management &c.) Even granting these misunderstandings, hospice care is still not being provided as often as it could (should) be. As the Atlas points out, many patients are dying in hospitals, rather than more nurturing environments.

Much of what hospice organizations do is alleviate caregiver overburden, help family/loved ones to prepare for and deal with the consequences of someone’s passing–everything from support groups to helping people get paperwork in order.

My experience is that hospice organizations are doing some of the most effective and important work in healthcare. Oh, and hospice care is often more cost-effective than other benefits to patients with terminal diagnoses.

This article from Politico.com mentions the high cost of the 5% sickest patients. They are, in fact, the most costly patients to care for.

But I have a question about regression to the mean (and perhaps exiting the system–aka, death). Isn’t it the case that the sickest 5% of patients are likely not to be the 5% sickest patients next year, simply because of regression to the mean?